Nokea
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should
- A. Place a call to the client's healthcare provider for instructions
- B. Send him to the emergency room for evaluation
- C. Reassure the client's wife that the symptoms are transient
- D. Instruct the client's wife to call the doctor if his symptoms become worse
Correct Answer: B
Rationale: In this scenario, the client is presenting with concerning symptoms of lethargy and confusion after a fall. These symptoms could indicate a serious underlying issue, such as a head injury or internal bleeding. The nurse's priority is to ensure the client receives immediate evaluation and treatment to prevent any further harm. Option B is the correct choice as it emphasizes the urgency of the situation. Choices A, C, and D are incorrect because they do not address the critical nature of the client's condition. Contacting the healthcare provider, reassuring the wife, or waiting for symptoms to worsen could delay necessary medical intervention.
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A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct?
- A. Scarlet fever is caused by infection with group A Streptococcus bacteria.
- B. "Strawberry tongue"? is a characteristic sign.
- C. Petechiae occur on the soft palate.
- D. The pharynx is red and swollen.
Correct Answer: C
Rationale: Petechiae on the soft palate are not a typical finding in scarlet fever. Scarlet fever is caused by group A Streptococcus bacteria, often presenting with a strawberry tongue, red and swollen pharynx, and a sandpaper-like rash. The presence of petechiae on the soft palate is more commonly associated with conditions like rubella rather than scarlet fever. Therefore, this description is not correct in the context of scarlet fever.
A mother has recently been informed that her child has Down syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down syndrome?
- A. Simian crease
- B. Brachycephaly
- C. Oily skin
- D. Hypotonicity
Correct Answer: C
Rationale: Individuals with Down syndrome commonly have certain physical characteristics, such as a simian crease (single transverse palmar crease), brachycephaly (shortened front-to-back skull dimension), and hypotonicity (low muscle tone). Oily skin is not a characteristic associated with Down syndrome; instead, individuals with Down syndrome often have dry skin. Therefore, oily skin is the correct answer in this context.
When taking a patient’s history, she mentions being depressed and dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking?
- A. Amitriptyline (Elavil)
- B. Calcitonin
- C. Pergolide mesylate (Permax)
- D. Verapamil (Calan)
Correct Answer: A
Rationale: The correct answer is Amitriptyline (Elavil) as it is a tricyclic antidepressant commonly used to treat symptoms of depression and anxiety disorders. Amitriptyline works by increasing the levels of certain neurotransmitters in the brain to improve mood. Choices B, C, and D are incorrect. Calcitonin is a hormone used in the treatment of osteoporosis; Pergolide mesylate is a dopamine agonist used in Parkinson's disease; Verapamil is a calcium channel blocker used to treat high blood pressure and certain heart conditions, not mental health disorders.
The client is being prepared for insertion of a pulmonary artery catheter (Swan-Ganz catheter). What information does the client need to know about the purpose of this catheter insertion?
- A. Stroke volume
- B. Cardiac output
- C. Venous pressure
- D. Left ventricular functioning
Correct Answer: D
Rationale: The correct answer is D: Left ventricular functioning. The purpose of inserting a pulmonary artery catheter is to obtain information about left ventricular functioning when the catheter balloon is inflated. Choices A, B, and C are incorrect because while a pulmonary artery catheter can provide information on stroke volume, cardiac output, and venous pressure, its primary purpose is to assess left ventricular function.
A client has no pulse or respirations. After calling for help, what should the nurse's first action be?
- A. Start a peripheral IV
- B. Initiate high-quality chest compressions
- C. Establish an airway
- D. Obtain the crash cart
Correct Answer: B
Rationale: In a situation where a client has no pulse or respirations, the initial action recommended by the American Heart Association is to start high-quality chest compressions. This action helps maintain blood flow to vital organs such as the brain until normal heart rhythm is restored. Starting CPR with chest compressions before checking the airway and providing rescue breaths is crucial to improve outcomes. While establishing an airway and obtaining a crash cart are important steps in resuscitation, initiating chest compressions takes precedence to ensure oxygenated blood circulation. Starting with chest compressions applies to adults, children, and infants but not newborns.